Yoga for Arthritis

Sample Yoga Poses for Arthritis PatientsSteffany Haaz, MFA, RYT

Updated: 6/23/2009

Introduction

Holistic (or mind-body integrating) movement practices with origins in eastern philosophy and culture are receiving a great deal of attention recently. For many adults, yoga, t’ai chi, qi gong, and various dance forms are joining the treadmill and exercise bike as way to safely and effectively increase physical activity. Having arthritis should not prevent individuals from trying these alternatives to traditional exercise. However, for many people, yoga, in particular may bring to mind pretzel-like poses requiring considerable strength and balance. In reality, beginner yoga classes provide simple, gentle movements that gradually build strength, balance, and flexibility – all elements that may be especially beneficial for people with arthritis. In this article, Steffany Haaz MFA, a professional choreographer, certified movement analysis (CMA), registered yoga teacher (RYT) and Research Coordinator with the Johns Hopkins Arthritis Center will demystify yoga for arthritis patients and their providers.

What is yoga?

Yoga is a set of theories and practices with origins in ancient India. Literally, the word yoga comes from a Sanskrit work meaning “to yoke” or “to unite.” It focuses on unifying the mind, body, and spirit, and fostering a greater feeling connection between the individual and his/her surroundings. Yoga has spiritual roots, with the main goal of helping individuals to realize true happiness, freedom, or enlightenment. Beyond this, however, yoga has several secondary goals, such as improving physical health and enhancing mental well-being and emotional balance(1).

As interest in yoga has increased in western countries over the last few decades, yoga postures are increasingly practiced devoid of their original spiritual context, solely for physical health benefits. This physical practice of yoga, often called Hatha Yoga, sometimes overlaps or includes references to the other aspects of yoga. A popular misconception is that yoga focuses merely on increasing flexibility. The practice of Hatha Yoga also emphasizes postural alignment, strength, endurance and balance. Table 1 offers an overview of several of the more common styles of Hatha yoga (including those most appropriate for people with arthritis).

What are the benefits of yoga?

Over 75 scientific trials have been published on yoga in major medical journals. These studies have shown that yoga is a safe and effective way to increase physical activity that also has important psychological benefits due to its meditative nature. As with other forms of exercise, yoga can increase muscle strength, improve flexibility, enhance respiratory endurance, and promote balance(2-4). Yoga is also associated with increased energy and fewer bodily aches and pains.(5, 6) Finally, yoga is associated with increased mental energy as well as positive feelings (such as alertness and enthusiasm), fewer negative feelings (reduced excitability, anxiety, aggressiveness) and somatic complaints(5, 6). In summary, yoga is associated with a wide range of physical and psychological benefits that may be especially helpful for persons living with a chronic illness.

Additionally, physical activity is an essential part of the effective treatment of osteoarthritis (OA) and rheumatoid arthritis (RA), according to treatment guidelines published by the American College of Rheumatology(7, 8). In persons with arthritis, exercise is safe and does not exacerbate pain or worsen disease(9-12). In fact, exercise may play a key role in promoting joint health(13), since those who do not exercise often suffer more joint discomfort than those who do(14). The health and psychological benefits of exercise are widely recognized(15, 16). However, regular physical activity is especially important for people with arthritis, who often have decreased muscle strength, physical energy, and endurance(17), in part due to their arthritis and the tendency to be sedentary(18). Being sedentary can began a downward spiral where pain increases, leading to more inactivity which leads to greater pain and disability. The psychological benefits of exercise such as stress reduction, fewer depressive symptoms, improved coping and well-being and enhanced immune functioning(19-22) also contribute to greater overall health.

Have scientific studies of yoga been done in arthritis patients?

While there is a great deal of anecdotal evidence of the benefits of yoga (just visit any yoga studio), to date only a handful of scientific studies have been conducted on persons with OA and RA (though several more are currently underway). These early studies have shown promising results with some improvement in joint health, physical functioning, and mental/emotional well-being(23-25). Perhaps most importantly, yoga has an important positive effect on quality of life. People with arthritis may also enjoy yoga more than traditional forms of exercise, and exercise enjoyment is an important predictor of adherence(26, 27). This is particularly important considering that, on average, 50% of sedentary individuals will drop out of exercise within 6 months(28).

In summary, yoga can be a meaningful and enjoyable alternative to traditional forms of exercise such as aerobics or aquatic exercise with important health benefits. Yoga can play an important role in reducing stress and frustration that results from pain and disability, and increasing positive feelings and wellbeing. Drug treatments for OA and RA have improved markedly in the last few years. Despite this, arthritis cannot be cured, and even the best medications and medical care can only help so much. There is a great need for additional activities patients can do to reduce pain, disability, and take control of the overall impact arthritis may have on their lives. Thus, the evidence suggests that, when combined with a program of good medical care, yoga may provide important additional physical and psychological health benefits for arthritis patients. Scientists at Johns Hopkins Arthritis Center hope to be at the forefront of exploring this relationship through rigorously conducted clinical research trials.

If you are interested in learning more about yoga, read on. We hope you will find the following information and resources useful.

What is the best way to try yoga?

Yoga can be a safe and effective form of physical activity, but as with any new activity, it is important to take proper precautions. Talk with your doctor and ask specifically if there should be any limitations or restrictions your doctor wants you to observe. (If your doctor has specific recommendations, ask for them in writing and give this to the yoga instructor.) The best introduction to yoga is generally a beginner class, led by a qualified teacher who can guide you in the safe and healthy execution of modified poses.

How do I find a qualified yoga instructor and yoga classes?

The Yoga Alliance is the national certifying body for yoga instructor and facilities. You can search the Yoga Alliance website for a list of certified yoga instructors in your area. You can contact an instructor directly for information about classes and/or private instruction. Private lessons will be more costly, but will ensure that you receive proper attention and guidance, particularly if you are just beginning, or have special needs or concerns related to your arthritis.

Another option is to find a yoga studio in your area (the phone book is a good resource). Some yoga studios may offer specialized classes for older individuals or people with arthritis or other mobility challenges. Beginning or Gentle Yoga classes also are widely available in YMCAs, health clubs, community and seniors centers. Always ask about the credentials of instructors at these locations. When attending your first class, be sure to arrive a few minutes early and take time to introduce yourself to the instructor and explain your condition. If your doctor has placed any specific restrictions or limitations on physical activity, tell the instructor about these before the class begins.

Questions you should ask when selecting a class

  1. What is the style of yoga offered in the class?
    The combination of asanas (poses) and pranyama (breathing practices) is generically called “Hatha Yoga.” Because yoga has been passed down through many teachers to many students, many schools or styles have emerged with different methods of practice. Some of these styles are fairly gentle and safe for students with arthritis, while others should generally be avoided. See Table 1 for more information about various styles of Hatha Yoga.
  2. Is the instructor certified?
    Yoga Alliance is the accrediting body for yoga instructors worldwide. Being certified by Yoga Alliance requires a minimum level of training in techniques, anatomy/physiology, teaching methodology, philosophy/ethics, and practical experience. You can find a certified teacher by visiting the Yoga Alliance and searching in your area.
  3. Do you offer beginner or gentle yoga classes?
    Some classes combine students with varied experience, and provide modifications for each level. Especially when first beginning to practice yoga, it is helpful to be in a class geared toward beginning students.
  4. How long has the instructor been teaching?
    While this is not always the case, teachers with more experience are often more adept at modifying poses for each individual and are likely to have continued training for students with special needs.
  5. Does the instructor have a medical background or experience teaching students with arthritis?
    This is an ideal scenario. Try to find a teacher who is familiar with your condition and can guide you in making the proper adjustments for your body. Short of this, classes offered through hospitals or medical settings are often supervised or overseen by medical staff.

What can I expect to do in a beginning yoga class?

There are three main components to most western yoga classes: poses (asanas), breathing techniques (pranyama), and relaxation. Some classes will also include additional elements such as meditation or chanting.

The types of poses that are usually included in beginning or gentle yoga classes are simple standing and seated poses. This introduction helps students to increase their awareness of the body and its relationship to space in a safe and gradual manner. Many people have fears that they may be asked to try standing on their heads or twisting into a pretzel-like position. These practices are part of yoga, but are only recommended for very advanced practitioners and will not be included in beginner classes. Additionally, an important aspect of yoga is that it is non-competitive. Students work at their own ability level, being sure to respect the body and its limitations. You should never go beyond what is comfortable and reasonable and a good yoga instructor will help you determine what is appropriate for you in each pose. All yoga poses can be modified for your safety and comfort, to accommodate any special needs you may have.

Components of a Yoga Class

Asanas
Asanas are a series of poses designed to bring about greater health and well being. The poses are combined in a predictable sequence that addresses strength, flexibility, and balance of the whole body. Poses are held for variable lengths, depending on the experience on the participant, characteristics of the pose and the style of yoga being practiced. Most poses can be easily modified to account for a student’s level of experience and physical condition. Some teachers utilize props, such as blocks, straps, or blankets to help students adjust challenging poses. While originally, the asanas were created to prepare the body for sitting still in meditation, they have evolved as a physical practice and are considered by many to be a moving meditation themselves.

Asanas are the yoga practices that require the most guidance and special attention for individuals with arthritis. If something seems too challenging or causes discomfort, you and the instructor can arrive at an appropriate modification.

Pranyama
Breath is an important aspect of many yoga classes. Movement should be connected with the breath throughout yoga practice. In some poses, this means moving one direction on an inhale and the opposite direction on an exhale. Some teachers also instruct students to hold a pose for a particular number of breaths. Independent of the asanas there is another set of breathing practices to invigorate or calm the body and mind, which should only be practiced with a qualified instructor. A good resource for learning more about breathing practices is “Science of Breath” A Practical Guide” by Alan Hymes, MD.

The breathing techniques taught in beginner yoga classes are generally safe for anyone, including those with asthma or COPD, as long as they feel comfortable. If you have a lung condition, you may want to speak with your doctor about the safety of advanced breathing practices, and be sure to tell your yoga instructor about any concerns you might have.

Deep Relaxation
At the closing of class, most teachers incorporate some type of relaxation for somewhere between 1 and 15 minutes. This is usually done in Savasana or Corpse Pose (lying on the back with eyes closed). The purpose of this relaxation is to absorb the stress and tension-reducing benefits of the asanas, so that a sense of calm and ease will carry over from the practice after the class had ended. It also relates to the original purpose of Hatha practice, relaxing the body so that it can remain completely quiet for a more meaningful meditation. In American yoga classes, the deep relaxation is often considered a reward at the end of class, though for the restless, it can often be the most challenging.

Deep relaxation is beneficial for all persons and generally requires no modification. If you are pregnant, or if lying on your back for prolonged periods is painful, your yoga instructor can suggest alternate poses for relaxation.

Meditation
Some classes include brief periods of seated meditation before or after the asana practice. During these times, some instructors give guidance on how to approach meditation. It is a time to quiet and focus the mind, relieving it of the unnecessary clutter of trivial thoughts that stream in and out during the day. This discipline of the mind is said to allow greater spiritual awakening, but can also simply provide relief from the day’s stresses. Meditation can have any focus, such as the breath, an image, an idea or affirmation, a sound, or a personal prayer.

Modifications to the traditional cross-legged seating pose are an option for those with arthritis. Other seated positions can be used, and props such as a chair or block may be helpful.

Chanting
Sound vibrations can be very powerful, capable of breaking glass, or even causing an avalanche. The healing properties involved with making various sounds have also recently been studied(30). Beyond healing, chants have historically served the purpose of unifying communities, or fostering an individual sense of spirituality. Not all yoga classes incorporate chanting, but some more traditional styles consider chanting to be an essential aspect of Hatha practice. Most chants in yoga class incorporate words for peace (Shanti) or words that have no translation, but are said to reflect natural universal vibrations (Om). If you don’t feel like joining in with the chant, it is perfectly acceptable just to listen. It is important to note that, unlike singing, there is no judgment of quality in chant. It is a sound, not a song that is being created, though it is often beautiful and moving. (For more information on chanting, see Robert Gass, “Chanting: Discovering Spirit in Sound.”)(31).

No modifications are required for people with arthritis.

Can I practice yoga even if I am relatively sedentary and inflexible?

Absolutely. In fact, individuals with limited range of motion or poor flexibility, due to arthritis or otherwise, may benefit the most from yoga practice, as it can increase flexibility, strength, and balance. Even if you are unable to kneel or have difficulty getting up and down, modifications are available. There are some “chair yoga” classes that are taught entirely in a seated position! It may feel a bit disheartening at first when challenges arise, but overcoming such judgments and accepting where you are is an important part of yoga.

A core concept of yoga is to always honor what will allow you to benefit most from the practice. Your yoga teacher will emphasize the importance of always listening to your body, recognizing your current limitations, and approaching your yoga practice from there. Yoga is not competitive, and the focus should not be on how the pose looks (aside from ensuring safe anatomical alignment). It is about experiencing a connection of the body and mind through the breath. While there are some yoga poses that do require a great deal of flexibility, strength, and balance, those poses should only be attempted by very experienced yogis and are NOT for beginners or persons with activity limitations. Again, a good yoga teacher will provide alternatives and modifications to all activities so that students can work within their levels of comfort.

Are there any poses people with arthritis should avoid?

The general rule for arthritis patient (and people in general) is that if it hurts, stop. The old adage of “no pain, no gain” does not apply to yoga, particularly if you have activity limitations. When doing backbends, arthritis patients should keep them relatively small and be aware not to hyper-extend the neck, keeping the head in line with the rest of the spine. For those with arthritis of the hip, be cautious when doing “hip openers” or poses with extreme external rotation of the hips. Generally, you will notice pain if you are going too far with the pose, but sometimes the effects are not felt until the next day. It is important to be gentle with your practice, especially at first. If you do not experience any pain after a few days, you can decide to gradually increase the intensity of the poses. There have also been some indications that strength training targeted at the quadriceps muscles might not be recommended for those with malaligned or lax knees(29). However, interventions that balance opposite muscle groups and exercises that improve muscle awareness (such as yoga) might help stabilize the knee. As with any condition, it is important to be cautious and pay attention to your body. Also, be sure to consult your doctor and instructor if you experience any pain or difficulty resulting from yoga practice.

What should I bring to my first yoga session?

Wear comfortable clothing that allows for full movement of the body. If the clothing is too loose, the instructor will be less able to guide you in proper alignment, but it should also not be restrictive. Clothing specially designed for yoga is available, but unnecessary. Yoga is traditionally practiced barefoot, though it may be possible to wear socks at the start of class, until the body warms up. “Sticky” mats are used in modern yoga practice to provide some cushioning and prevent slipping. Some studios or gyms will supply mats for general use. You may want to inquire about this in advance. Also, be sure to bring water or an empty container for filling, in case they are not supplied. It is important to stay hydrated during any physical activity.

Can I practice yoga at home?

While not recommended for those who are completely new to yoga, as you become more confident and experienced, you may want to supplement classes with home practice. There are also many yoga books and videos available, but they do not necessarily address the needs of arthritis patients. The Arthritis Foundation has a video titled “Yoga for Arthritis – Pathways to Better Living with Arthritis and Related Conditions” and can be found through stores and online retailers. You can also visit their website. While the video is safe for most patients with arthritis, it cannot provide the same level of supervision and individual attention offered by working with a qualified instructor.

Where can I find more information?

Listed below are several resources that offer safe and practical information about yoga.

  • Yoga Journal, information for those new to yoga
    Yoga Journal is a monthly publication for yoga practitioners and instructors. It contains information about specific poses, places to practice, the history and philosophy of yoga, and links to many additional resources.
  • Yoga Research and Education Center (YREC), articles and general information
    YREC is a resource for therapists, instructors, and practitioners with the aim of providing information about the historical teachings and cultural heritage of yoga. They are also linked with IAYT (below) to better investigate the physiological and psychological contributions yoga may have for health and wellness.
  • International Association of Yoga Therapists (IAYT), bibliographies for yoga and specific health conditions

References

  1. Yoga Research and Education. 2003. www.yrec.org
  2. Madanmohan, Thombre DP, Balakumar B, Nambinarayanan TK, Thakur S, Krishnamurthy N et al. Effect of yoga training on reaction time, respiratory endurance and muscle strength. Indian J Physiol Pharmacol 1992; 36(4):229-233.
  3. Schell FJ, Allolio B, Schonecke OW. Physiological and psychological effects of Hatha-Yoga exercise in healthy women. Int J Psychosom 1994; 41(1-4):46-52.
  4. Gauchard GC, Jeandel C, Tessier A, Perrin PP. Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects. Neurosci Lett 1999; 273(2):81-84.
  5. Wood C. Mood change and perceptions of vitality: a comparison of the effects of relaxation, visualization and yoga. J R Soc Med 1993; 86(5):254-258.
  6. Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry 1995; 17(3):192-200.
  7. Hochberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA, Griffin MR et al. Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee.American College of Rheumatology. Arthritis Rheum 1995; 38(11):1541-1546.
  8. Newsome G. Guidelines for the management of rheumatoid arthritis: 2002 update. J Am Acad Nurse Pract 2002; 14(10):432-437.
  9. Minor MA. Exercise in the treatment of osteoarthritis. Rheum Dis Clin North Am 1999; 25(2):397-415, viii.
  10. Bearne LM, Scott DL, Hurley MV. Exercise can reverse quadriceps sensorimotor dysfunction that is associated with rheumatoid arthritis without exacerbating disease activity. Rheumatology (Oxford) 2002; 41(2):157-166.
  11. O’Grady M, Fletcher J, Ortiz S. Therapeutic and physical fitness exercise prescription for older adults with joint disease: an evidence-based approach. Rheum Dis Clin North Am 2000; 26(3):617-646.
  12. Ettinger WH, Jr., Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997; 277(1):25-31.
  13. Forrest G, Rynes RI. Exercise for rheumatoid arthritis. Contemp Intern Med 1994; 6(11):23-28.
  14. Nordemar R, Ekblom B. [Effects of long-term physical therapy in rheumatoid arthritis]. Lakartidningen 1981; 78(15):1561-1564.
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  16. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. 1996. Atlanta, GA, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.
  17. Lyngberg K, Danneskiold-Samsoe B, Halskov O. The effect of physical training on patients with rheumatoid arthritis: changes in disease activity, muscle strength and aerobic capacity. A clinically controlled minimized cross-over study. Clin Exp Rheumatol 1988; 6(3):253-260.
  18. Eichner ER. Exercise and arthritis. The hematology of inactivity. Rheum Dis Clin North Am 1990; 16(4):815-825.
  19. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts. Sports Med 2000; 29(3):167-180.
  20. Fox KR. The influence of physical activity on mental well-being. Public Health Nutr 1999; 2(3A):411-418.
  21. Scully D, Kremer J, Meade MM, Graham R, Dudgeon K. Physical exercise and psychological well being: a critical review. Br J Sports Med 1998; 32(2):111-120.
  22. Taylor CB, Sallis JF, Needle R. The relation of physical activity and exercise to mental health. Public Health Rep 1985; 100(2):195-202.
  23. Dash M, Telles S. Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. Indian J Physiol Pharmacol 2001; 45(3):355-360.
  24. Garfinkel MS, Schumacher HR, Jr., Husain A, Levy M, Reshetar RA. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. J Rheumatol 1994; 21(12):2341-2343.
  25. Haslock I, Monro R, Nagarathna R, Nagendra HR, Raghuram NV. Measuring the effects of yoga in rheumatoid arthritis. Br J Rheumatol 1994; 33(8):787-788.
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  29. Sharma L, Dunlop DD, Cahue S, Song J, Hayes KW. Quadriceps strength and osteoarthritis progression in malaligned and lax knees. Ann Intern Med 2003; 138(8):613-619.
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  31. Gass R. Chanting: Discovering Spirit in Sound. New York NY: Broadway Books, 1999.

Table 1

*yellow indicates for arthritis patients
STYLE FOUNDER CHARACTERISTICS RECOMMENDATIONS
*for arthritis patients in yellow
Ananda Swami Kriyananda Very gentle. Preparation for meditation. Directing of energy. Affirmations combined with poses. Longer meditation may be difficult for arthritis patients.
Anusara John Friend (student of B.K.S. Iyengar) Anatomically-based. Emphasis on opening the heart. Extensive teacher training. Recommended for most arthritis patients.*
Ashtanga K. Pattabhi Jois (student of Sri T. Krishmanacharya) Specific sequence. Continuous movement. Very strenuous. Not recommended for arthritis patients due to physical rigor.
Bikram/Hot Bikram Choudhury Taught in 100-110 degree room to expel toxins and increase mobility. Not recommended for arthritis patients due to extreme heat.
Integral Swami Satchidananda (student of Swami Sivananda) Gentle practice including poses, breathing, chants, and meditation. Recommended for most arthritis patients.*
Iyengar B.K.S. Iyengar (student of Sri T. Krishmanacharya) Strong anatomical basis. Uses props to individualize poses. Recommended for most arthritis patients.*
Kripalu Amrit Desai Taught in three stages with evolving emphasis. Stage One focus on learning poses and understanding body. First stage recommended for most arthritis patients.*
Kundalini Yogi Bhajan Intended to awaken latent spiritual energy through poses, breathing, meditation. Intensity of breathing techniques may be challenging for some patients.
Sivananda Swami Vishnudevananda (student of Swami Sivananda) Gentle practice including poses, breathing, chants, and meditation. Recommended for arthritis patients.
Viniyoga Sri. T. Krishnamacharya Individualized practice. Breath and movement very coordinated. Extensive teacher training. Recommended in private sessions for most arthritis patients.*

Updated: October 10, 2012

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